"YOU A DOCTOR? Where's your white coat?"
The question comes from an elderly lady wrapped in two hospital gowns, hair in pink curlers. She peers suspiciously at me over the end of the bed. This week she developed diabetes on top of her severe alcoholic liver disease, anemia, bleeding hemorrhoids and recurrent bladder infections.
She's been here at George Washington Hospital for more than a month now, and I am her doctor. Some days she remembers me; some she doesn't. I dread the day she'll go home. One drink and she'll be in trouble again, but she adamantly refuses to consider being placed in an alcohol program.
People who know me well have learned it's not part of my make-up to wear that white coat, if I can help it. It just doesn't work. It never stretched sufficiently to cover a pregnant belly; it traps too much elbow. Psychologically, it seems to separate me from those who have asked me to participate in their care. Some people expect it, but for me it's a distancing mechanism, and that's not something I like.
This woman, however, is not a believer. It might be easier to make her recognize she needed help if I were 6 feet tall, 65 years old and male, like some of my colleagues. The medicine we practice isn't so different, but the image conveys a lot.
Occasionally, however, the absence of a white coat pays off in an unexpected way: One wizened little gentleman, charming but demented, was convinced that his social worker and I, since we did not wear those official-looking coats, were around the hospital for no better reason than to keep him company in bed. Regularly, he invited us to climb in and cuddle up. He wouldn't hear anything about "doctor," and by the time he finally left we were all a bit relieved.
But four days later there was a frantic carom the daughter-in-law who had kindly agreed to care for him at home, so he wouldn't need to be institutionalized. He was trying to get her 12-year-old daughter into bed with him, she sobbed.
"Did he touch her?" I asked, immediately concerned.
"No, never. Only kept talkin' to her to come in."
"Oh," I replied, relieved. "That's no problem, he always does that with me too." An audible gasp at the other end of the line. Then we talked about the confusion that sometimes affects elderly people, and I explained that he seemed to be confusing women around him with his late wife. He had never pressed an invitation, I reassured her, and after his recent stroke I didn't think he ever could. She was able to tell her child that Grandpa just mistook her for someone he had once cared about, and that she should ignore him.
Had he remained troublesome, I suppose we could have gotten the young woman a white coat.
Medical school orientation, an annual event with an eager audience. As the class of 1988 filed into Ross Hall to hear something about what their lives would be like during the next four years, I was sprawled on the beach at Bethany with my 18-month-old daughter at my feet. My first class -- the first, that is, to come to George Washington since I became director of admissions last May. I should have been there to tell them something about themselves as a group. Instead, as Annie scooped sand through a Mickey Mouse sifter, trying industriously to bury our blanket, I was attempting to figure out how we will replace Jane, who has been taking care of her since December. She leaves next month, and we've been juggling schedules trying to make everything fit.
I was also celebrating an anniversary. Ten years earlier, I had been one of those people listening in Ross Hall, wondering how my own life was going to change. A series of documents on my office walls cut back across that time, diplomas and certificates artifically marking changes that were both abrupt and so gradual that I don't pretend to understand all of them yet. The diplomas confirm that I am a doctor, but how it happened and what it means are better expressed in fragments of memory and experience.
As the Atlantic capriciously crept toward our blanket, bringing delighted shrieks from Annie, Robert Frost's poem "Neither Out Far Nor in Deep" popped into my mind, reminding me of the years before medicine, when there had been much more time for poetry, and when that poem had seemed an apt metaphor for what was happening to me.
Until my own orientation in 1974, I had been on The Post's staff, in Book World. Before that, there had been nine years of writing and editing, interrupted by a brief foray into literature at Columbia University that left me with Ivory Tower acrophobia. I did love journalism, but personally felt neither out far nor in deep, a dilettante, facile with words but not very challenged by my life. I seemed to be skimming too rapidly along the surface, with nothing to draw me in.
Medicine had never merited a thought 10 years earlier at Brandeis; issues like getting federal troops out of Vietnam and into Mississippi seemed much more compelling to a Florida girl in the middle of intellectual and political ferment for the first time. Those of us studying literature or sociology or politics tended to disdain the grinds who spent their nights in the laboratory and their days buried in their textbooks; they were so predictable, so dull.
But medicine began to loom large in my mind in 1971, after a bellyache turned out to be appendicitis and the diagnosis was missed. By the time a doctor operated, looking for an entirely different problem, I had developed peritonitis, a serious abdominal infection. That hospitalization was miserable. I remember getting nine or 10 needlesticks during one morning after an intravenous line clotted, and moaning to the staff to leave me alone to die because anything was preferable to being stuck again. I certainly didn't understand the niceties of surgery, but I knew how it felt to lie awake for five hours after the operation not knowing which of my internal parts had been removed, wondering if I'd ever be able to have a baby.
"It was just your appendix," the doctor told me cheerfully when I finally begged a nurse to help me call his office to find out what had been done. Granted, I was young and silly and scared, but I still don't know if the tears after that were more from rage or from relief.
It wouldn't take much, I thought to myself, to do better than that. That's how simple it was. An idea born of personal vanity (I was sure I could make people more comfortable than I'd felt myself), untutored and half- foolish.
I'm amused when I remember that now. Motivation is of such great concern to some on our admissions committee: they want to know someone has thought out the decision to go into medicine. My own belief is that what your motivation happens to bewhen you decide to study medicine has little to do, in most cases, with what you want by the time you're hooked.
While I had constructed an acceptable if not elegant rationale for my own interest in medicine, I didn't for a minute put any stock in what I was saying. I told some people it was a logical progression from an interest in saving the world to an interest in working within the political system in order to improve living conditions here, to an urge -- after McCarthy didn't get elected -- to work as an individual to effect positive changes in the lives of other individuals. I told others that it was because I wanted to prove that a reasonably literate person could do just about anything. Sometimes I said it was because my father was a doctor. For all I knew, I might have wanted a secure job that would let me leave the cities if I decided to.
And I had fantasies about medicine, including a fantasy that it wouldn't be difficult. I didn't even realize until my sophomore year that residency training followed an internship. When I found out there were those two extra years of indenture, I was depressed for days. I had been gloriously, abysmally ignorant before I began.
As Watergate took over its pages, I worked days at The Post and at night crammed in biology, physics and genetics classes. At 30 I suddenly felt much older, dubious about leaving the secure job that I enjoyed. When an acceptance arrived from George Washington in December 1973, the bewilderment was whether to take the plunge. If I hated it, I could always retreat, I reasoned. I signed the contract.
Most of us go into medical school having touched life skin deep, knowing a bit about our bodies and not much about anyone else's. The first, abrupt transition occurs in the anatomy lab where students get under the skin and take a long, slow look at the way people are put together.
One of the most surprising lessons for me was that people do not lose expressiveness, even in deah. Some appear pathetic and vulnerable, others stern or quiet. And while the scientist in me attempted to submerge my human reactions in the need to dissect and to learn, the poet kept muttering Dylan Thomas's "Do not go gentle into that good night."
The man who had been generous enough to donate his body, allowing my group to study it, we found out, had been a doctor himself. A doctor! I was shocked and very much moved, and am even more so now, as I imagine the courage it would take for me to consign my own earthly remains into the hands of medical students, people whose insecurity faced with this difficult experience at times leads to bad jokes or less than gentle handling of those they get to know with such unreal intimacy.
My daughter, who babbles "Mommy" when she's pleased to see me and howls "Carole" when she's mad, had just slathered her red plastic shovel across a bucket of sand which she overturned to make another of her cakes. She grew up chewing the rubber tubing of my stethoscope, and she carries my beeper around the house pressing the button to make squeaky noises, so I suppose she knows what it means to be a doctor's daughter (or, more properly, the daughter of two doctors, since my husband is a psychoanalyst).
She let us know she was arriving unexpectedly one night, kicking through her amniotic sac at 11 p.m. after I'd been working all day. Her sense of geography is evidently as good as mine -- she presented with one foot down, like a ballerina, and needed to be extricated by Caesarean section. She's been dancing ever since, thanks in part to the people who have cared for her. I'm worried about what will happen in October. Annie is very attached to the woman who has been with us, and it is going to be hard to find someone as good to replace her.
It would be impossible for me to work and to think about what was happening at the hospital if I didn't know Annie was happy and thriving. I had to make a deal with myself when it was time to return to work three months after she was born -- if things turned sour at home, that would be the end of the job. Not that I want to take on full- time child care!
Annie was very much a planned and a wanted baby, but she wasn't planned until quite late. I was 39 years old shortly after she was born, and while there are advantages to being an older mother, inexhaustible energy is not one of them. We brought along someone to help with her this year, and it means we really had a vacation.
Reluctantly, we piled our sandy blankets and buckets into the car, jammed full of diapers, bathing suits and the paraphernalia of three adults, including the portable computer on which my husband was revising his manuscript, a psychobiography of Samuel Taylor Coleridge which has been part of our lives now almost as long as we've had a relationship. We drove home.
I am on the faculty now at George Washington, working with residents and medical students, and practicing internal medicine in addition to my work with the admissions office.
The days are never 9 to 6. Winters, the files of medical school applicants keep me company from the time Annie falls asleep until 10 or 11 at night. Saturday mornings there are patients to visit in the hospital or applicants to interview. And, because I'm member of the internal medicine faculty, there are three-or four-day stints of accepting patients into the hospital who have conditions too complicated to be handled in the emergency room. If my husband didn't love to cook, there would be no guarantee Annie or I would eat anything but peanut butter at home.
I am an internist. You might call internal medicine the first line of defense against illness. We are detectives of sorts who try to analyze why a patient is sick. We also handle a broad range of conditions. Anything from diabetes and high blood pressure to emergencies like asthma attacks are our problem. When a condition is beyond my experience, I consult subspecialists who concentrate on more restricted areas of medicine, in which they become quite expert.
I chose internal medicine because none of the subspecialties interested in me as much as that concept of doctor as detective, and because the people you deal with are such an interesting mix of the healthy and unwell. My friends thought I would become a psychiatrist. Listening and offering too much advice had been such a long-time avocation that they must have thought the temptation to do it for a living would be overwhelming.
But internal medicine allows me to be a psychologist of sorts, and actually gives me an opportunity to say much more than many people trained in that field are permitted to -- and to talk to almost anyone I please, since so many medical problems have roots in the psyche.
Monday morning, for example, a woman who had a breast malignancy five years earlier worries: "I'm tired all the time . . . ." The unspoken fear -- has the cancer come back?
We begin to talk about her days -- and her nights. It turns out she is tired because she has been awakened frequently by a nightmare that bothered her years earlier: rats crawling under the bed.
She tells me incidentally about a daughter she saw recently after many years' separation, and mentions that she is anxious about some of the girl's problems, difficulties not unlike those my patient faced as a young woman. In my mind, I am associating rats under the bed with those old problems that were coming up again. We talk about nightmares as a metaphor for a variety of troubling thoughts that may not yet have pentrated a person's conscious awareness, and I tell her the connection that occured to me. I examine her, find no evidence of a recurrence of the cancer, but order a few simple tests. She leaves, relieved, with instructions to dig around and try to figure out what her dream means.
Then a scribble from my secretary: There's a phone call from a tense young woman who wants help for an eating disorder. She has been abusing laxatives, swallowing seven or eight at a time to induce diarrhea, in order to rid herself of the food on which she intermittantly binges. She's scared. She feels out of control, and ashamed. Now between binges, she knows she needs help. I wonder anxiously about Annie; when she becomes an adolescent, will this thinness craze still be spawning such unhappy victims?
Both of these people have real medical problems. But in each case, addressing the medical issues alone would solve very little. The pleasure for me, in the work that I do, comes from getting to know the entire person, working psychologically, too, in treating physical illnesses. These extraordinary opportunities to participate in the lives of people who are comparative strangers -- and to participate with so much intimacy -- were not even imaginable to me before I changed careers.
There is an old joke that has made the rounds at the medical school:
A long line of people wait patiently at the Pearly Gates and St. Peter interviews them, one by one. But one character in a white jacket, stethoscope flung over his shoulder, rushes impatiently past everyone else and bursts through the gates.
"Who does he think he is -- God?" someone asks indignantly.
"No," replies St. Peter. "That is God. He just thinks he's a doctor."
By the time I got to medical school, doctors were already disturbed that people were interpreting as arrogance the inability of some doctors to communicate well. Their worries were heightened by the increasing number of malpractice suits, and their concerns were trickling down to the classrooms.
The definition of an effective doctor was changing, as indeed it probably has through the history of the profession. Being expert technically was not enough. Communications skills became much more important. So incorporated into my medical education were classes in which we learned about the kinds of relationships doctors could have with their patients.
Some people are comfortable with a "paternal" person; others need a more cooperative relationship, we were taught. If people like you, if they believe you are doing your best, and are communicating fully and candidly with them, even if things go wrong, they probably won't sue you. It seems like common sense, but there it was, on paper, for any who couldn't figure it out for themselves.
One blessing of knowing that no one wants you on a pedestal is that you don't have to pretend you're anything but human.
Particularly poignant is the memory of a sweet black man who came to the Veterans Hospital, where I was training, after he developed a blood clot in his leg. It had broken loose and lodged itself in his lung. He arrived with severe pain in his chest, short of breath, but after a week of anticoagulation therapy, he felt more comfortable.
Suddenly, one afternoon, he began to vomit up masses of blood. The drugs we were using prevented clotting of what must have been an abraded spot in his stomach. As I began to slip a tube down his throat so we could try to constrict the blood vessels and staunch the bleeding with iced salt water, another piece of old clot dislodged from that leg and reached the lungs. He gasped, stopped breathing, and died there in my arms. Our resuscitation attempts were useless.
I cried with his family, and cried for hours after that, as I wandered around the ward doing endless tasks an intern must do. Late that night, another doctor sat up with me, remembering the tragedies that had most affected him and sharing his own reactions with me.
The empathy and the release it permitted let me cope with that painful loss, and helped me to tolerate other losses since then. If, professionally, we were required to swallow grief or rise above it, the toll in alcohol or drug abuse, depression and suicide might be much higher.
Being allowed to be myself during training helped me to survive. Now that I'm practicing, that's what makes medicine satisfying for me.